What happens when routine surgery results in bad outcomes?Complications during surgery, while rare, are among the most feared situations surgeons face. Beyond the immediate challenge of stabilising the patient, surgeons must also manage the emotionally charged conversations with families, institutional reporting processes, and the possibility of medico-legal repercussions.
At the recent ENT Summit, held in Kuala Lumpur, a discussion was held on the topic of managing adverse outcomes after surgery. The multidisciplinary panel featuring Professor Dr Joseph K Han, Professor Dr Michael Tong Chi Fai, and medicolegal lawyer Raja Eileen Soraya, moderated by Associate Professor Dr Yap Yoke Yeow, explored the issues around handling catastrophic surgical complications.
Han presented a real-world case involving a carotid artery injury during endoscopic sinus surgery (ESS). The panel then discussed surgical judgement, communication with patients and families, disclosure obligations, supervision in training centres, and the importance of honesty and professionalism when complications occur.
Han, a professor in the Department of Otolaryngology & Head and Neck Surgery at Old Dominion University (Eastern Virginia Medical School), US, presented the case of a 74-year-old man with chronic pansinusitis who underwent ESS after failed medical therapy. The patient had underlying hypertension and coronary artery disease, but imaging otherwise showed typical pansinusitis without major abnormalities.
The surgery was initially performed by a chief resident under Han’s supervision. During sphenoidotomy, bleeding occurred. Initially, the bleeding was thought to arise from a posterior septal artery, a recognised but usually manageable complication during ESS. However, concern later arose that the injury may have involved the internal carotid artery.
Discussion
According to Tong, Head of Graduate Division of Otorhinolaryngology and Communication Sciences, Chinese University of Hong Kong, once unexpected bleeding occurs, the supervising surgeon must relook the situation directly and determine whether the bleeding source has been adequately controlled before proceeding further with surgery.
Raja Eileen, management partner with the Messrs. Raja, Darryl & Loh, highlighted that from a medicolegal standpoint, failure to identify the source of bleeding could later become a point of scrutiny. At the same time, she acknowledged the practical realities surgeons face intraoperatively, including balancing prolonged operative time against the need to further explore the surgical field.
Ultimately, surgery was completed before the area was reassessed. When the nasal packing was slowly removed, profuse bleeding recurred. This led to the activation of an emergency response, and the patient was brought for urgent interventional radiology (IR) assessment. Angiography confirmed bleeding from the right internal carotid artery. This was subsequently coiled after adequate collateral circulation was demonstrated. Although the bleeding was controlled, the patient later developed embolic strokes with neurological deficits.
The recurring themes throughout the discussion was the importance of timely and transparent communication with the patient’s family. Raja Eileen reiterated that disclosure should occur at the earliest opportunity. She noted that concealment or delayed disclosure often causes greater medicolegal problems than the complication itself.
Importantly, the panel differentiated factual disclosure from assigning blame. Tong advised that communication with the family should focus on what occurred, what interventions were undertaken, and the ongoing management plan, rather than speculating on fault or causation.
Han also reflected extensively on the emotional burden associated with these conversations. He described the difficulty of seeing the patient and family daily after the complication but emphasised that maintaining visibility and honesty was necessary to preserve trust.
The discussion also touched on the increasingly recognised concept of the clinician as the “second victim.” Being the moderator, Yap noted that medicolegal events are often psychologically traumatic not only for patients and families, but also for the healthcare professionals involved.
Another major point raised was the consultant surgeon’s responsibility in teaching institutions. Han explained that trainees were routinely introduced to patients during the consent process, and that the involvement of residents was explicitly documented in consent forms.
However, the panel agreed that ultimate responsibility remains with the supervising consultant. Raja Eileen warned against situations where junior doctors are left to explain complications to families on their own. The most senior responsible clinician should take charge of discussions following adverse events.
The panel also discussed the thorny issue of apologising following complications. Concerns are often raised about whether saying “sorry” could be taken as an admission of guilt. Tong advised against statements that explicitly imply negligence or fault. He, however, recognised that expressions of empathy are human and also appropriate. He said patients and families often value honesty and compassion over technical explanations.
Han said that he apologised to the family because he genuinely felt sorry for the outcome. At the same time, he avoided blaming the resident or other team members, repeatedly mentioning that he was the responsible surgeon.
The panel additionally discussed how seemingly minor language choices during preoperative counselling may later become highly significant. Han recalled that the patient’s wife later questioned why a surgery he described as “easy” resulted in serious complications. He no longer describes operations as “easy” or “straightforward,” regardless of their perceived complexity.
Raja Eileen agreed strongly with this point, noting that families often struggle to reconcile severe complications with prior reassurance that surgery was routine. She advised surgeons to consistently communicate that all surgical procedures carry risks, even in experienced hands.
The management of carotid artery injury itself also generated considerable discussion. Tong pointed out that no universally accepted algorithm exists for managing iatrogenic carotid injury during ESS, partly because such events are rare.
While Han questioned in hindsight whether a muscle graft alone might have avoided the embolic stroke associated with angiography, Tong noted that interventional radiology (IR) involvement is now commonly considered standard practice in many centres dealing with carotid blowout or vascular injury.
Finally, the panel discussed the importance of documentation and preservation of evidence, including surgical video recordings. Raja Eileen advised that operative videos should be preserved as part of the medical record and disclosed appropriately if litigation occurs. Interestingly, she pointed out that video evidence is often in favour of the defence, objectively showing what happened in the intraoperative sequence of events.